Assessment #3: Professional Repot Assessment Overview This written assignment is to be presented in the form of a professional report. There are many types of professional report that social workers may write, including reports requested by courts, the coroner, and presenting assessment and intervention information for client records or case reviews. For this assignment, you will need to imagine yourself in the position of a hospital social worker who has completed a bio-psycho-social-assessment (Don’t forget spiritual, sexual, cultural aspects of the assessment) with the person at the centre of the case study. You are writing a professional report as part of referral to a colleague in the community. That colleague may be an Accredited Mental Health Social Worker or another professional (such as a psychologist, psychiatrist, occupational therapist, or specialist counsellor service). A report accompanying referral is a representation of your professional judgement and an introduction for your client to this new professional. Things to remember: • It is good practice to give the person a copy of your referral report. Keep this in mind as you write – write it in a way that you would be happy for that person to read! • You will need to analyse the information in the case study in order to develop a clear assessment as your rationale for your referral. That means more than summarising descriptive information. • You will need to incorporate your knowledge from the social work literature to analyse the information available in the case studies. • All the case studies have partial information – avoid making stuff up if it’s not there, work with what you have. You may note that some important elements will require further assessment A couple of resources for developing and structuring an assessment: Singer, J. B. (Producer). (2007, January 22). Bio-psychosocial-Spiritual (BPSS) assessment and Mental Status Exam (MSE) [Episode 2]. Social Work Podcast [Audio podcast]. Retrieved from http://socialworkpodcast.com/2007/02/bio-psychosocial-spiritual-bpss.html Drisko, J.W. & Grady M.D (2012) Appendix A An Outline for a Biopsychosocial Assessment and Intervention Plan in Evidence Based Practice in Clinical Social Work New York, Springer Science+Business Media pp.259-302 (pdf below) – especially look at sections I- V, VII, VIII, X There is no specific structure required. What you will need to do is have some structure and a clear presentation of the client situation, your assessment of their health and wellbeing needs, and a summary formulation that provides a clear rationale for why you are referring them to your colleague for additional support as part of a discharge plan.
Professional Report on Case Study 6: Jack
Social workers have a responsibility of writing professional reports for referral purposes to different individuals and bodies. As such, according to Corcoran and Walsh (2009), they have to conduct a bio-psycho-social-assessment of their clients which will be utilized as the basis of referral to a colleague in the community. Notably, the assessment usually contains a summary of the problems identified by the social worker and recommendations which are based on the evaluation and professional judgment (Singer, 2007). The assessment ought to communicate pertinent information about the client to colleagues for both case planning and referral purposes. Additionally, it provides the account of where the client is at a particular moment and thus offers bassline information before he/she enters an agency for services (Drisko & Grady, 2012). This paper provides a professional report prepared by a hospital social worker for jack, a 12-year male. The report will analyze the findings of an assessment of his health and wellbeing and recommendations or referral to a psychologist.
Assessment of Jack’s Health and Wellbeing
Jack is a 12-year-old male who was brought to my practice room by his father, Karl, because he was presenting various difficulties in school. The first step that I made was to conduct a strengths-based assessment of the client by deploying the bio-psycho-social-assessment (Corcoran & Walsh, 2009). Prior to the evaluation, Jack and his father were informed about the purpose of the assessment as well as the limits of confidentiality. Additionally, they were both informed that the assessment required both personal information as well as the clinical impressions and treatment recommendations of the examiner (Bond and Mitchels, 2008). The following were the different assessments done and findings established:
- Biological Assessment
In the biological assessment, the aim was to look at the basic needs of the client including his food, shelter, clothing, health, medical as well as physical capabilities in the physical environment (Drisko & Grady, 2012). Jack lives with his father Karl who is a single parent; considering that his mother died when he (Jack) was a baby. Both Jack and her father have had to move to numerous places because of work which has resulted in Jack shifting schools. Neither Jack nor his father reported any biological needs which are unfulfilled. On the contrary, Jack has managed to transit to high school education without any problems. The fact that Jack and his father have moved to different places is not pegged on any biological needs but rather due to his father’s work.
- Psychological Assessment
According to Singer (2007), a psychological assessment examines the history, intelligence, personality style, and the mental abilities of the client. In the case of jack, he rated among the best 15 percent for the state in the latest National Assessment Program – Literacy and Numeracy (NAPLAN) test. As such, he is not only smart but also intelligent. However, he has recently struggled to pay attention to what the teacher says. Additionally, he often finds himself going “blank” and feeling that his head has nothing at all. Of late, Jack has struggled with maths in school. However, despite all those issues, he still possesses impressive reading and comprehension skills. One of the strengths is that Jack can read epic novels in short period. Additionally, he can describe the readings very accurately. As such, he holds a high degree of intelligence as such features cannot be found in an average student. The personality of Jack is that of a withdrawn person who does not like to interact with others as he has refused to participate in school activities and neither does he want to be part of the Italian language learning class.
- Socio-Cultural Assessment
In the socio-cultural assessment, the focus was on the examination of Jack’s friends, family, community, and his social environment (Lawrence et al., 2015). Jack stays with his father; a single parent, following the death of his mother when he (Jack) was a baby. Jack has lived in different social environments because his father’s work has forced them to move to numerous places. As such, Jack has had to make new friends. Although Jack does not want to participate in school sports activities day, and neither does he want to be part of the Italian learning language classes, he had made new friends at the high school. Additionally, he is not bullied and has good relations with most of the teachers.
- Spiritual Assessment
In the spiritual assessment, the aim was to examine Jack’s sense of self, sense of meaning and purpose, as well as his value base and religious life (Berzoff & Drisko, 2015). The assessment did not reveal any religious affiliations associated with Jack. However, he seemed to have a strong sense of meaning and purpose. He believed that because he had learned a different language in primary school, then there was no point in learning Italian.
- Sexual Assessment
The sexual assessment examination aimed at establishing whether Jack was subject to any form of sexual abuse as well his knowledge of sexual matters (Andrasik, Goodie, & Peterson, 2015). There was no information provided as to the sexual understanding of Jack. His father; Karl, did not mention as issues related to sexual issues to do with Jack. No information was provided as to whether Jack understood his body and whether he has been in any relationship with girls.
Based on the bio-psycho-social-assessment of Jack, various strengths can be established. One of those is that he is a smart and intelligent boy who needs to be helped to achieve his education and life goals. Notably, from the NAPLAN test done in the state, Jack was among the top 15 percent best students which shows that he did well in the exam. Being top in the examination implies that he has a higher level of intelligence compared to other students (Lawrence et al., 2015). Additionally, Jack is gifted because he can read long novels within a very short time. Moreover, he can even comprehend the information in the stories which demonstrates that he is highly intellectual. Furthermore, the assessment has shown that Jack is smart. Also, the fact that he could make new friends in the new high school despite him moving numerous schools demonstrates that he is adaptable to different situations.
Despite the strengths of Jack, there are various areas of weakness where he needs the help of mental health practitioners. One of those is that he does not have motherly love because his mother died when he was young and thus has only lived with his father (Oh et al., 2015). Additionally, he has had to deal with people from different communities and schools considering that he has moved numerous places with his father. Furthermore, he has difficulties interacting with other students considering that he refused to engage in the school’s sports day activities. Notably, in such events, students will have to interact since most of the sports are performed in groups. Jack’s needs arise from loneliness and isolation which have impacted on his ability to concentrate in class. He seems to have many negative thoughts which will need to be handled by a professional.
Conclusion and Recommendations
It has been assessed that the current mental health status of Jack is not healthy and if the current situation continues, it might impact the academic performance of Jack as well as his cognitive functioning. Unless measures are taken to address the mental health problems faced by Jack, then there is a high likelihood of him suffering from emotional harm in the future. Additionally, there is a severe problem if Jack continues to refuse to engage in social activities such as sports and language learning. The intelligence that Jack possess needs to be applied in an environment where he is focused and comfortable. Although he does not say it, Jack is affected by the absence of his mother and the fact that he father had not been in a relationship since his (Jack) mother’s demise (Worden, 2003). Although Jack has the social support of his father and friends in school, he needs to be counseled on the needs to interact and share his issues with friends and close confidants.
Psychological support is required to ensure that these mental health concerns are addressed to enable Jack to concentrate in class and relate well with his peers in school. To ensure that Jack continues to perform well and that he focuses in class, it is vital that the various negative thoughts he has in his mind are removed. I consider that the best intervention is to place him to a psychologist. Jack needs the necessary cognitive therapies which will ensure that he recovers from the death and absence of his mother and focuses on his academics. Additionally, he needs to be provided with treatments to boost his self-esteem and get the confidence to interact with other students in school. Your additional support on jack will be vital in ensuring her metal stability and changing her personality from that of a withdrawn person to a confident and social individual.
Andrasik, F., Goodie, J. L., & Peterson, A. L. (Eds.). (2015). Biopsychosocial assessment in clinical health psychology. Guilford Publications.
Berzoff, J., & Drisko, J. (2015). What clinical social workers need to know: Bio-psycho-social knowledge and skills for the twenty first century. Clinical Social Work Journal, 43(3), 263-273.
Bond, T. and Mitchels, B. (2008) Confidentiality and record-keeping in counselling and psychotherapy. Los Angeles; London: SAGE.
Corcoran, J., and Walsh, J. (2009) Mental health in social work: a casebook on diagnosis and strengths-based assessment Boston, MA: Pearson/Allyn and Bacon.
Drisko, J.W. & Grady M.D (2012) Appendix A: An Outline for a Biopsychosocial Assessment and Intervention Plan in Evidence Based Practice in Clinical Social Work. New York, Springer Science+Business Media pp.259-302
Lawrence, D., Johnson, S., Hafekost, J., De Haan, K. B., Sawyer, M., Ainley, J., & Zubrick, S. R. (2015). The mental health of children and adolescents. Report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Canberra: Department of Health.
Oh, E., Mathers, M., Hiscock, H., Wake, M., & Bayer, J. (2015). Professional help seeking for young children with mental health problems. Australian Journal of Psychology, 67(3), 187-195.
Singer, J. B. (Producer). (2007, January 22). Bio-psychosocial-Spiritual (BPSS) assessment and Mental Status Exam (MSE) [Episode 2]. Social Work Podcast [Audio podcast]. Retrieved from http://socialworkpodcast.com/2007/02/bio-psychosocial-spiritual-bpss.html
Worden, J. (2003). Grief counselling and grief therapy: a handbook for the mental health practitioner. 3rd edition. Hove, East Sussex: Brunner-Routledge.